Attachment J.27 Business Declaration.docx
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- Solicitation number
- 693KA8-20-R-00008
About this file
This Screening Information Request (SIR) issued by the Federal Aviation Administration (FAA) is seeking proposals for a Direct Current Back-Up System (DC BUS) power supply indefinite delivery indefinite quantity (IDIQ) contract. The anticipated contract would have a two-year base period and four two-year option periods, for a potential ten-year period of performance. The FAA requires life cycle in-service support of COTS/NDI DC BUS uninterruptible power supplies to provide conditioned power to critical National Air Space communication and electronic equipment. Proposals are due by March 27, 2020. The FAA will provide responses to questions and requests for clarification by March 18, 2020. Offerors must comply with instructions in Section L. This is not a contract but rather a market survey to determine interest in a future procurement.
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PART IV – REPRESENTATIONS AND INSTRUCTIONS
SECTION K – REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS OF OFFERORS
PART IV – REPRESENTATIONS AND INSTRUCTIONS
SECTION K – REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS OF OFFERORS
SIR 693KA8-20-R-00008
Attachment J.27: Business Declaration
| 1. Name of Firm: ______________________________ | Tax Identification No.: _______________ | |
| 2. Address of Firm: ____________________________ | DUNS No.: ___________________ | |
| 3. a. | Telephone Number of Firm: _________________________ |
b. Fax Number of Firm: _____________________
4. a. Name of Person Making Declaration: _____________________________________
b. Telephone Number of Person Making Declaration: _________________________
c. Position Held in the Company: ___________________________________________________
5. Controlling Interest in Company (“X” all appropriate boxes)
b. Hispanic American c.
Native American
d. Asian American
a. Black American
| e. Other Minority (Specify): _________________ | f. Other (Specify): ___________________ | |
| g. Female | h. Male | i. 8(a) Certified (Certification letter attached) |
j. Service Disabled Veteran Owned Small Business
6. Is the person identified in Number 4 above, responsible for day-to-day management and policy decision making, including but not limited to financial and management decisions?
a.
Yes
b. No (If “NO,” provide the name and telephone number of the person who has this authority.)
7. Specify North American Industry Classification (NAIC) code _______________________________________
8. Nature of Business (Specify all services/products (NAIC)) __________________________________________
| 9. a. Years the firm has been in business ___________________ | b. No. of Employees ____________________ | |
| 10. Type of Ownership: | a. Sole Ownership | b. Partnership |
c. Other Explain)
Gross receipts of the firm for the last three years:
a.1. Year Ending a.2. Year Ending a.3. Year Ending b.1. Year Ending b.2. Year Ending b.3. Year Ending
12. Is the firm a small business?
a. Yes ____ b.
No ____
13. Is the firm a service disabled veteran owned small business?
a. Yes ____ b.
No ____
14. Is the firm a socially and economically disadvantaged small business?
a. Yes _____
No _____
15. Is the firm a woman-owned small business?
a. Yes _____
No _____
I DECLARE THAT THE FOREGOING STATEMENTS CONCERNING ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. I AM AWARE THAT I AM SUBJECT TO CRIMINAL PROSECUTION UNDER THE PROVISIONS OF 18 USCS 1001.
16. a. Signature: ___________________________ b. Date: ___________________
c. Typed Name: ________________________ d. Title: ___________________
Privacy Act Statement: Privacy Act Statement (5 U.S.C. § 552a, as amended). AUTHORITY: FAA Acquisition Management System (49 USC 40110) authorizes us to collect this information. PURPOSE(S): We will use the information provided to determine your business ownership and eligibility for contracts set-aside for certain types of businesses. ROUTINE USE(S): We may share your information among our offices involved in small business development and contracting, and may also use the information for statistical reporting. DISCLOSURE: Providing the requested information is voluntary; however failure to furnish the information may result in ineligibility to participate in set-aside contracting.
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